Hypertension, Re defining Normal Blood Pressure ; Is Lower Better ? ASEAN FAMILY MEDICINE CONGRESS IPOH, PERAK 20 TH JUNE 2019
CRITERIA FOR 'NORMAL PRESSURE' - HISTORICAL PERSPECTIVE pre - 1960 1960-1980 WHO WHO/JNC/ISH JNC 1980s 1990s 2000s High BP is Normal SBP is 100 <160/95mmHg <140/90 mmHg pre HPT essential and + age introduced should not be SBP 120-139 mmHg intervened DBP 80-89 mmHg
CRITERIA FOR 'NORMAL PRESSURE' - CURRENT STATUS AHA/ACC MSH ESC/ESH November 2017 January 2018 August 2018 <130/80 mmHg <140/90 mmHg < 140/90 mmHg
CRITERIA FOR DIAGNOSIS EVIDENCE ?
EPIDEMIOLOGY CV mortality risk 8 7 6 5 4 3 2 1 0 115/75 135/85 155/95 175/105 Blood pressure (mm Hg) * i ndividuals aged 40-70 years, starting at BP 115/75 mm Hg Lewington et al. Lancet 2002 JNC VII. JAMA 2003
AHA /ACC 2017 “ Categories were based on a pragmatic interpretation of BP related CVD risk and benefit of BP reduction in clinical trials”
There is only ONE trial so far Baseline BP 138/82 , CV Risk < 10% CV Death, MI, Stroke, Cardiac Arrest, Revasc, HF SBP Placebo HR (95% CI) P Trend Cutoffs Mean Diff Event Rate% ≤131.5 122 6.1 3.5 1.25 (0.92-1.70) 0.009 131.6-143.5 138 5.6 4.6 1.02 (0.77-1.34) >143.5 154 5.8 7.5 0.76 (0.60-0.96) 0.5 1.0 2.0 Candesartan + HCTZ Better Placebo Better
BP Lowering Arm: Conclusions • Fixed dose combination of Candesartan 16 mg + HCTZ 12.5 mg/day reduced BP by 6.0/3.0 mmHg, but did not reduce CV events • CV events were significantly reduced in the highest third of SBP – SBP >143.5 mmHg, mean 154 mmHg • Results were neutral in the middle third, and trended towards harm in the lowest third of SBP • Treatment increased lightheadedness, but not syncope or renal dysfunction
Algorithm for the Management of Hypertension BLOOD PRESSURE (Repeated Measurements) SBP 160 mmHg SBP = 130 – 159 mmHg and/or and/or DBP 100 mmHg DBP = 80 – 99 mmHg Assess global Drug treatment, (consider Medium / High / cardiovascular risk combination therapy Very High (refer to Table 4&5) except in the older adults )* * Either free or single pill combination Low- Intermediate 3 – 6 monthly follow-up with advice on non-pharmacological management and reassess CV risk SBP 140 mmHg SBP < 140 mmHg and and/or DBP 90 mmHg DBP < 90 mmHg Drug 6-monthly follow-up treatment
BP Target in the Elderly ACP/ AAFP AHA/ACC MSH ESC/ESH January 2017 January 2017 January 2018 August 2018 < 150/90mmHg < 130 mmHg < 130/80 mmHg SBP 130-139 <140/90 mmHg ( avoid SBP < 130 mm ) < 150/90 mmHg DBP < 80mmHg > 60 years >65yrs > 65 yrs > 65 yrs
SPRINT - SYSTOLIC BP Year 1 Mean SBP 136.2 mm Hg Standard Mean SBP 121.4 mm Hg Intensive
SPRINT Primary Outcome Cumulative Hazard Hazard Ratio = 0.75 (95% CI: 0.64 to 0.89) Standard (319 events) Intensive (243 events) During Trial (median follow-up = 3.26 years) Number Needed to Treat (NNT) to prevent a primary outcome = 61 Number of Participants
Primary Outcome Experience in the Six Pre-specified Subgroups of Interest *Treatment by subgroup interaction
HYVE HYVET T - Blood Blood pr pressur essure e separ separation tion 180 170 15 mmHg 160 150 Blood Pressure (mmHg) 140 Placebo 130 Indapamide SR +/- 120 Median follow-up 1.8 years perindopril I 110 100 6 mmHg 90 80 70 0 1 2 3 4 5 Follow-up (years)
The Older Adult - Malaysian CPG Older Adult Population Target Systolic BP > 80 years old < 150/90 mmHg 65-80 years old < 140/90 mmHg Multiple Comorbidities Consider less strict targets Functional and Cognitive Impairment Limit numbers of antihypertensive agents Frail , Institutionalized Experiencing ADR Fit 65-80 years old < 130/80mmHg ( free from health conditions that limit mobility and/or functional ability with good nutrition and cognitive status
BP TARGET FOR DIABETIC HYPERTENSIVES JNC 8 AHA/ACC MSH ESC/ESH 2014 2017 2018 2018 < 140/80mmHg ( 1 st objective ) < 140/90mmHg < 130/80mmHg < 140/80mmHg SBP < 130 mmHg( if well tolerated ) SBP < 120mmHg ( should be avoided ) DBP < 70mmHg ( should be avoided )
ADA 2017 ADA 2017 changed target from 140/80 mm Hg to 140/90mmHg “ These targets are in harmony with JNC8 ( 2014 ) recommendations of a DBP threshold of < 90 for individuals > 18 years of age with diabetes. A BP of < 80mmHg is still appropriate for patients with long life expectancy, CKD, elevated UAE, evidence of CV disease or additional risk factors such as dyslipidaemia, smoking or obesity
Hypertension Trials in Diabetes Trial Year Entry BP BP difference Outcome UKPDS 1998 160/94 154/ 88 vs 144/82 POSITIVE ADVANCE 2007 145/81 140/77 vs 135/75 POSITIVE ACCORD 2010 139/76 134/71 vs 119/ 64 NEGATIVE
BP TARGET FOR HYPERTENSIVES WITH PREVIOUS CVA AHA/ACC MSH ESC/ESH 2017 2018 2018 < 130/80mmHg < 140/90mmHg SBP 120-130mmHg < 130/80 for lacunar stroke
PATS: Blood pressure Baseline BP 154/93mmHg 160 Placebo Systolic 155 Indapamide 2824 150 2338 1582 1528 145 Blood 140 pressure 95 Diastolic (mmHg) 92 2841 89 86 2148 1678 1302 83 0.0 0.5 1.0 1.5 2.0 2.5 3.0 Time since randomisation (years) PATS Collaborating Group, Chin. Med. J. 1995; 108: 710-7.
PROGRESS Baseline BP 147/86mmHg End of study BP 138/82mmHg Blood pressure (mmHg) 160 N=3054 140 N=3051 120 Mean difference Active treatment Placebo 100 9.0/4.0 mm Hg 80 60 B R 1 3 6 9 12 18 24 30 36 42 48 54 Follow-up time （ months) Lancet. 2001;358:1033-1041.
BP TARGET FOR HYPERTENSIVES WITH CONCOMITANT IHD AHA/ACC MSH ESC/ESH 2017 2018 2018 < 130/80mmHg < 130/80 mmHg SBP < 130/ < 80 mmHg SBP NOT < 120 / 70 mmHg
BP TARGET FOR HYPERTENSIVES WITH CONCOMITANT CKD AHA/ACC MSH ESC/ESH 2017 2018 2018 < 140/90 mmHg < 130/80mmHg ( proteinuria < 1g/day ) SBP 130-139 mmHg < 130/80 mmHg ( proteinuria > 1g/day )
CONCLUSIONS Only 2 new RCTs over the last 5 years to add to the existing body of evidence on BP targets Based on global surveys, we are still struggling to reach < 140/90mmHg when treating patients Strongest evidence is to get all patients < 80 years' BP < 140/90mmHg In higher risk patients < 130/80mmHg can be the target ( evidence strongest with lacunar stroke ) but care is needed as to not do more harm than good
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